CHHS18/114

Canberra Hospital and Health ServicesOperational Procedure Emergency Department Information System (EDIS) – Data Validation Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Preparation of Validation Reports..........................................................................2

Implementation........................................................................................................................ 3

Related Policies, Procedures, Guidelines and Legislation.........................................................4

References................................................................................................................................ 4

Search Terms............................................................................................................................ 4

Attachments..............................................................................................................................4

Attachment 1: Daily Data Validation Reports........................................................................6

Attachment 2: Triage Category waiting time exceeded........................................................7

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Purpose

For various reasons, there are inconsistencies in the information entered in the Emergency Department Information System (EDIS). As a result, data validation is required.

This Operational Procedure provides guidance to the EDIS System Administrators on which records to audit and which data they are allowed to edit in EDIS.

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Scope

This Operational procedure applies to the EDIS Administrators only. EDIS administrators are employed by ACT Health within the division of Critical Care

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Section 1 – Preparation of Validation Reports

1. Run, save and print the following reports DAILY: ‘Excess Triage Category Wait’ and ‘Triage Excess Percentage’ The timeframe for these reports are for the previous day, from midnight to

midnight.2. Next, run the other 21 data validation reports (see Attachment 1) which identify other

data entry inconsistencies. Save any reports that flag incorrect data before any data validation is made. The timeframe for these reports are also for the previous day, from midnight to midnight. Edit all incorrect data identified in these reports

3. After the data has been corrected, re-run and print the ‘Excess Triage Category Wait’ Report. This report is used to review the ‘Doctor Seen By’ times. Apply the following parameters: Exclude ‘Did Not Wait’ Exclude ‘Triage Category 4’

4. The EDIS Administrator is required to review the clinical records of every patient on the list. Any one of the following list of documented evidence may be used to edit the ‘Doctor Seen By’ times:a. Time seen as recorded in patient notesb. Time of arrival for Triage Category 1 patients sent into Resuscitation – Code Trauma,

Air Ambulance Retrieval, Intubated, Cardiorespiratory Resuscitation (CPR) in progress and straight to Resuscitation.

c. Time of commencement of a medically approved and supervised protocol (Chest Pain Pathway, etc.) For patients seen as part of the Chest Pain Pathway or where an ECG has been performed in the initial assessment, the recorded time of the

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Electrocardiograph (ECG) (following the protocol that all ECGs are to be shown immediately to a senior Emergency Department (ED) doctor for assessment)

d. The earliest time of a written medication or fluid order signed by a doctore. Correction of obvious errors (incorrect day, 12-hour versus. 24-hour clock, etc.)f. Comprehensive completion of the triage mental health checklist if all responses

marked as ‘No’ g. Earliest entry by mental health clinician on MAJICeR h. Earliest recorded doctor time on EDIS (Ctrl+H)

5. Any differences are recorded on the hard copy of the ‘Excess Triage Category Wait Report’ (See Appendix B).

6. The documented differences are then used to edit the ‘Doctor Seen By’ time in EDIS.7. When the editing is complete re-run and save the:

a. ‘Excess Triage Category Wait’” Report and save;b. ‘Triage Excess Percentage’ report and print.

8. Store the hard copies of before and after Triage Excess Percentage reports and the printed audit template with documented changes in ‘this month’s data’ folder. Audit records are only kept for about 3 months and sent to Records Management at Mitchell for secure storage, these reports are only retrieved if requested through an official inquiry process.

Outcome MeasureAccurate recording, or as close to, of the management of patients who attend the ED. The intention of this procedure is to ensure accurate recording or management of patients who attend the ED. Compliance with this procedure is monitored using [methods listed below”

Method My Hospitals:

o Waiting Timeso Time in Emergencyo Number of Patients

Score Card ED Validation Report National & Local KPI’s Performance Information Portal – ED Live

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Implementation

This document will be Available on the policy register on Sharepoint, discussed at orientation and in existing program of education for EDIS administrators

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Related Policies, Procedures, Guidelines and Legislation

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LegislationACT Health Records (Privacy and Access) Act 1997Electronic Transactions ACT 2001Territory Records Act 2002

PoliciesData Quality PolicySystem Security Plan: EDIS – Emergency Department Information SystemData Release PolicyAcceptable Access and Use of Information Technology (IT) PolicyData Custodian and Data Steward PolicyElectronic Emergency Department Operating System (EEDOS) Policy

Standards ACT Health Admitted Patient Activity Data StandardsNon-Admitted Patient Emergency Department Care NMDS 2014-15

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References

1. ACT Auditor-General’s Performance Audit Report2. Emergency Department Performance Information, Report No.6/2012, July 2012

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Search Terms

EDIS, Data, Emergency Department Information System, Validation, Waiting timesBack to Table of Contents

Attachments

Attachment 1: Daily Data Validation ReportsAttachment 2: Triage Category waiting time exceeded

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 14/03/2018 Full review ED, Critical Care CHHS PC

This document supersedes the following: Document Number Document Name

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Attachment 1: Daily Data Validation Reports

Referred from ED Downtime List

Referred by DOH Error Report

Patients Located in EMU NE check

No EPISI LMO Code Blank

ADMEPISI1 Short EMU Admissions

Bed Req – Depart Mismatch Doctor Specialty Mismatch

Depart Dest – Ward Mismatch Overlapping Episodes

Deaths Incomplete Admissions List

DUP2 EDIS Edits Prior to 48 Hours After

Discharge

Did Not Wait Date-Time Mismatch

Ward Comparison Folder

Refer to the EDIS Administrator Local Procedure Manual located in the EDIS Administrator office for further details on these reports.

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Attachment 2: Triage Category waiting time exceeded

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